Neonatal Surgical Unit RHSC and SCBU The Simpson

Management of the baby with suspected or proven NEC depends upon the Bell stage. Care of other concomitant conditions will be determined by the responsible Consultant Neonatologist. If a surgical opinion at The Simpson is requested then the baby will be seen by either a Consultant or Specialist Registrar. Babies with clear evidence of perforation would normally be transferred to RHSC for surgery as soon as possible after initial resuscitation and need not be seen by the surgeon prior to transfer as this my introduce unnecessary delay.

Babies referred from units outwith Edinburgh with Stage II or III disease should be transferred to the NSU for assessment.

Stage 1

• Withhold feeds.
• TPN.
• Antibiotics – Piptaz Vanc
• Close observation (including repeat X-rays) and general supportive care.

Stage 2

• As above.
• Urgent surgical referral (seen within 4-6 hours at The Simpson).
• Sequential abdominal X-rays (supine and lat decubitus or lat shoot through) 8 to 12 hourly until stable or if any deterioration.
• Paracentesis if:-
  • Erythema / Oedema of abdominal wall
  • Portal Vein Gas
  • "Fixed loop"
  • Abdominal mass
  • Clinical deterioration (falling platelets etc)

Stage 3

• As above + Volume resuscitation and correction of acidosis, metabolic and haematological abnormalities
• Immediate surgical referral and transfer once initial resuscitation completed. Transfer should not be delayed for full correction of acidosis, thrombocytopaenia or coagulopathy.

• • Pneumoperitoneum - Surgery (Laparotomy or Drain)
  • No Pneumoperitoneum - Paracentesis
• If too sick for transfer then surgeon will see at SMMP with a view possible peritoneal drain.

Indications for Surgery

Laparotomy

• Pneumoperitoneum
• Positive Paracentesis
• Rapid Deterioration

Peritoneal Drainage under Local Anaesthesia

Must fill all criteria:

• Too sick for transfer or anaesthesia
• Proven NEC
• Generalised free gas

Proceed to laparotomy if:-

• Stabilises but no further improvement by 24 hours
• Second drain thought to be required

Technique of peritoneal drainage

Preferred site is Right Lower Quadrant. If a mass is present this should be avoided. Insertion of Penrose tubing into the peritoneal cavity under direct vision.

Paracentesis

Technique

After antiseptic preparation a 22 or 25 gauge needle on a 2 or 5ml syringe is inserted into either the right or left flank at a 45 degree angle. The syringe is gently aspirated as the needle is slowly advanced until free return of at least 0.5 ml of fluid occurs. The appearance of the fluid is noted and a specimen sent for immediate gram stain and culture. If there is a palpable mass in one side of the abdomen the Paracentesis should be performed on the opposite side.

Paracentesis may be repeated at 8 - 24 hour intervals if clinical deterioration occurs.

Flowchart

Bell Staging of NEC

Stage 1 (suspected NEC)

• Predisposed infant
• Systematic manifestations:
• temperature instability
• lethargy
• apnoeas
• bradycardias
• GI manifestations:
• feed intolerance,
• vomiting (may be bilious),
• occult blood in vomit or stool,
• mild abdominal distension.
• Abdominal radiographs - bowel distension only.

Stage 2 (definite NEC)

• As above
• As above + mild / moderate acidosis and / or thrombocytopaenia
• Persistent occult or gross GI bleeding, marked abdominal distension
• Abdominal radiographs show distension + bowel wall thickening, intramural gas, portal vein or a fixed loop

Stage 3 (advanced NEC)

• As above
• As above + shock, severe acidosis, electrolyte abnormalities, thrombocytopaenia, DIC
• Marked GI bleeding
• Abdominal radiographs may show pneumoperitoneum